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Fluid Management in the Trauma Patient

- See:
      - Transfusion Menu / Blood Product Menu
      - Subclavian Vein Catheterization and Internal Jugular Approach

- Assessment of perfusion: damage control orthopaedics
      - normal blood pressure (systolic), heart rate, urine output (≥30 mL/hr);
      - labs: base deficit, bicarbonate, and lactate

- Initial Fluid Resusitation in the Adult Trauma Patient:
      - initially the adult trauma pt should rapidly be given 2 liters of a balanced salt solution w/ observation of response;                  
      - if there is no improvement in vital functions, than an additional fluid load should be instituted with the addition of pRBC;
      - 1:1:1 Tranfusion of pRBC, FFP and platelets
            - Effect of a fixed-ratio (1:1:1) transfusion protocol versus laboratory-results-guided transfusion in patients with severe trauma: a randomized feasibility trial.
            - Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) Trial: design, rationale and implementation
            - Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial.

      - misc:
            - use of naloxonne, vasopressors, diuretics, and bicarbonate is rarely indicated in initial resuscitation of trauma patient;        
            - caution is observed in allowing water intake, as dangerous water intoxication may occur with intense thirst stimulus;            
            - many trauma pts will have elevated levels of antidiuretic hormone from trauma, whether or not shock has occurred;
            - serial hematocrit:
            - in early shock, tachnypnea leads to respiratory alkalosis followed by metabolic acidosis due to poor tissue perfusion and will
                      reverse w/ adequate volume has been restored;                                  

      - classification of hemorrhage:
             - 70 kg male holds approximately 5 liters of blood or equivalent of 25 units pRBC;
             - class I:
                     - loss of up to 15% of the blood volume or 4 units pRBC loss;
                     - normally does not cause a change in blood volume or pressure;
                     - w/ supine position, as much as 1000 ml of blood may be maintained w/o causing a significant increase in peripheral pulse;
             - class II:
                     - loss of 15% to 30% of blood volume or 4-8 pRBC loss;
                     - normally results in increased pulse but no change in systolic blood pressure;
                     - these patients can most often be resuscitated with a crystalloid, but some may require blood transfusion (pRBC);
             - class III:
                     - loss of 30% to 40% of circulating blood volume which is about 2 liters;
                     - this results in tachycardia and loss of systolicblood pressure and decreased mental status;
                     - patients are given 2 liters of saline over 20 min or less while blood is prepared;
                     - blood pressure should be maintained with crystalloid until blood is ready;
                     - w/ recurrent hypotension, give two more liters of crystalloid, and type-specific or non–cross-matched
                                universal-donor (i.e., group O neg) blood is given;
             - class IV:
                     - loss of more than 40% of blood volume;
                     - marked tachycardia, significantly decreased systolic blood pressure, cold and pale skin, severely decreased mental status,
                               negligible urine output;
                     - references:
                             - Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures.
                             - Fresh frozen plasma should be given earlier to patients requiring massive transfusion.
A high fresh frozen plasma: packed red blood cell transfusion ratio decreases mortality in all massively transfused trauma patients regardless of admission international normalized ratio.

                             - Effect of high product ratio massive transfusion on mortality in blunt and penetrating trauma patients
                             - Resuscitation Strategies in Trauma

- Types of Fluids:
     - crystalloid:
           - the major disadvantage of isotonic crystalloids is their limited ability to remain within the intravascular space;
           - LR by the end of a 1 liter infusion expands the intravascular compartment by only 194 ml;
           - the remaining 80% of fluid is lost to the intersitial space;
           - generally, two to four times as much crystalloid as 5% albumin or 6% hetastarch is required to achieve the
                    same physiologic endpoints; 
     - colloids:
           - greater ability to than crystalloids to remain within the intravascular space and therefore more efficient volume expanders;
           - approximately 90% of exogenous albumin can be found in the IV space 2 hrs after administered;
           - the serum half life of albumin is about 18 hrs; 
           - synthetic colloids such as (hetastarch, hespan) have similar volume expanding abilities;
     - plasmanate (plasma protein fraction)
           - is a 5% protein solution containing both albumin and alpha and beta globulins;
           - paradoxical hypotension has been noted during the infusion of plasma protein fraction and has been attributed to acetate,
                      present as a buffer, or the presence of Hageman factor fragments

- Resusitation for Infants and Children:
    - LR bolus 20 ml/kg x 2-3 as required                                    
    - then pRBC 10 ml/kg x 1                                                  
    - continue fluid administration until CVP > 5 mm Hg;                      

- Daily Fluid Requirements:
    - minimum requirements for fluid balance can be estimated from the sum of the urine output necessary to excrete the daily solute
            load (500 ml/ day) plus insensible (evaporative) water losses from the skin and resp tract (500-1000 ml/day) minus the amount
            of water produced from endo-genous metabolism (300 ml/day);                                          
    - the kidney must excrete about 600 mOsm of solute/day (primarily Na, K, and urea) in the normal adult;                                      
    - since the maximum urinary concentrating ability is 1200 mOsm/kg, the minimum urine output required to excrete the osmotic
            load is 500 ml/day;                                                        
    - it is customary to administer 2000-3000 ml of water daily to produce about 1000-1500 ml/day urine output, since there is
            no advantage gained by minimizing urine output;                   

    Damage Control Resusitation

    Hemoglobin drops within minutes of injuries and predicts need for an intervention to stop hemorrhage.

    Mortality after Fluid Bolus in African Children with Severe Infection